Print Form Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Minnesota St., Suite 222, St. Paul, MN 55101-5133 (651) 201-7507 FAX (651) 297-5259 TTY (651) 282-6555 WWW.DPS.STATE.MN.US APPLICATION FOR CLUB ON SALE RETAIL LIQUOR LICENSE An officer of the club seeking a license shall complete this application. This application and the proof of liquor liability i nsurance must be filed w ith the city clerk or the county auditor. To qualify for a license a club must have at least fifty members, bee n in continuous existence for at least three years, have an elected governing board and limit sales to members and bona fide guests only. The annual license fee is set by statute (M.S. 340A.408). Granting of a license by the city or county is discretionary. Workers Compensation Insurance Company. Policy # Licensee's MN Sales and Use Tax ID Number___________________To apply for MN sales and use tax number call (651) 296-6181 Licensee's Federal Tax ID # Corporation Name Club Trade Name or DBA License Location (Street Address) License Period FROM TO S tate Business Phone ( ) Municipality County Zip Code Building Owner's Name Building Owner's Address Are there any delinquent taxes on the property? Name of Member of Managing Board Yes DOB No Social Security # Club Manager's Name Address Name of Member of Managing Board DOB Social Security # Address Name of Member of Managing Board DOB Social Security # Address Name of Member of Managing Board DOB Social Security # Address The Licensee must have one of the following: CHECK ONE A. OR Liquor Liability Insurance (Dram Shop) - $50,000 per person: $100,000 more than one person: $10,000 property destruction: $50,000 and $100,000 for loss of means of support. ATTACH "CERTIFICATE OF INSURANCE" TO THIS FORM A Surety bond from a surety company with minimum coverage as specified above in A. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a market value of $100,000 or $100,000 in cash or securities. Date of Incorporation Number of Years of Continuous Existence of the Club B. C. OR Give Date of Club Charter If Veterans or Fraternal Organization Number of Years in Current Quarters Number of Club Members Members Will the Club be issued a Lawful Gambling License? YES NO American LegalNet, Inc. www.FormsWorkFlow.com Yes Yes Yes No No No 1. 2. 3. Are any members, officer, agents or employees paid profits from the sale of beverages to club members? Are any employees paid salaries? Has applicant, partners, officers or employees ever had any liquor law violations in Minnesota or elsewhere? If yes, give names, dates, and final outcome. Does any wholesaler or manufacture of alcoholic beverages own or have any interest in furniture, fixtures or equipment for the licensed premises? If yes, give details. During the past license year, has a Summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802? If yes, attach a copy of the Summons. Will you serve liquor on Sunday? Amount of Sunday License Fee Yes No 4. Yes Yes No No 5. 6. I certify that I have read the above questions and that the answers are true and correct of my own knowledge. Signature of Applicant Date IF LICENSE ISSUED BY THE COUNTY BOARD: REPORT OF COUNTY ATTORNEY Yes No I certify that to the best of my knowledge the applicants named above are eligible to be licensed. If no, state reason. Signature County Attorney County REPORT BY POLICE DEPARTMENT OR SHERIFF'S OFFICE Date This is to certify that the applicant, and the associates, named herein have not been convicted within the past five years for any violation of Laws of the State of Minnesota, or Municipal Ordinances relating to Intoxicating Liquor, except s follows: Police Department or Sheriff's Name Title Signature LICENSE APPROVAL OR DENIAL Signature City Clerk or County Auditor LICENSE APPROVAL OR DENIAL License Granted Denied Date Signature Director Alcohol & Gambling Enforcement License Granted Denied Date NOTICE A $30.00 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100.00 or 100% of the value of the check, whichever is greater, plus interest and attorneys fees. MS 604.113 ALL RETAIL LIQUOR LICENSEES MUST REGISTER WITH THE ALCOHOL, TOBACCO TAX AND TRADE BUREAU. FOR INFORMATION CALL (513) 684-2979 OR 1-800-937-8864 (PS 9016-09) American LegalNet, Inc. www.FormsWorkFlow.com